How the CMS Program Integrity Enhancements Affect You and Your Business

Program Integrity Enhancements to the CMS Provider Enrollment Process

Effective November 4, 2019, the Centers for Medicare & Medicaid Services (CMS) Program Integrity Enhancements to the Provider Enrollment Process goes into effect. This means that CMS and state plans have the authority to deny or revoke a provider’s or supplier’s enrollment based on the affiliates they do business with. Your organization’s ability to enroll providers will now be affected by companies you do business with currently, as well as companies you’ve been affiliated with for the past five years.

The new rule creates a disclosure obligation on the part of Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) providers or suppliers. CMS requires providers to disclose, within the previous five years, any direct or indirect affiliation with a provider or supplier that has uncollected debt; has been or is subject to a payment suspension under a federal health care program; has been excluded from Medicare, Medicaid or CHIP; or has had its Medicare, Medicaid or CHIP billing privileges denied or revoked.

How the CMS Program Integrity Enhancements Affect Your Business

Today, entities are required to thoroughly screen their providers, employees, suppliers and vendors. Provider or supplier enrollment into a federal health care program is based on accurate results confirming that these providers or suppliers are in full compliance with CMS requirements. With the new rule going into effect, entities must now screen their affiliates and are responsible for knowing whether or not their affiliates are excluded from government-funded programs. Your organization could be penalized for affiliating with companies who are excluded or who are involved in fraudulent or abusive behavior.

The failure of an organization to fully and completely disclose the affiliate information specified when the provider or supplier knew, or reasonably should have known of this information, may result in the denial of the provider’s or supplier’s initial enrollment application or the revocation of the provider’s or supplier’s current Medicare, Medicaid or CHIP enrollment. CMS can deny enrollment based on affiliation with a business who poses an undue risk of fraud, waste or abuse to your organization.

Verisys Offers a Solution to Keep Your Organization in Full Compliance and Free of Penalties

Verisys delivers the only market-ready solution that can track your affiliations’ current and historical data and conduct. Verisys can screen an entire company or an individual for exclusions and adverse actions that would prohibit them from taking part in federal health care programs. Affiliating with questionable or shady companies could deny your organization access to government-funded programs.

The new rule will hold entities accountable to know the companies they affiliate with and to avoid doing business with companies who are noncompliant or who engage in fraud, waste or abuse. This, in turn, can deter other parties from engaging with these shady businesses and it encourages organizations to be more selective in who they affiliate with going forward. Partnering with Verisys will aid you in making these important decisions and keep your organization in full compliance with CMS requirements.

Learn more about how Verisys can assist your HCOs in meeting all government and regulatory standards.

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